MEDICARE: EAST COAST PODIATRY INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	213ES0103X	Foot & Ankle Surgery Podiatrist

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	K0055	OTHER		MEDICARE GROUP NUMBER

General Provider Information

NPI Number	:	1104014208
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAST COAST PODIATRY INC

Provider Business Mailing Address
First Line	:	233 OSCEOLA AVE
Second Line	:
City	:	ORMOND BEACH
State	:	FL
Zip	:	32176-6638
Country	:	US
Telephone Number	:	386-672-6424
Fax Number	:	386-672-5251

Provider Business Practice Location Address
First Line	:	233 OSCEOLA AVE
Second Line	:
City	:	ORMOND BEACH
State	:	FL
Zip	:	32176-6638
Country	:	US
Telephone Number	:	386-672-6424
Fax Number	:	386-672-5251

Authorized Official
Title or Position	:	DPM / OWNER
Name	:	DR. DONALD C JOHNSON JR.
Credential	:	DPM
Telephone Number	:	386-672-6424

Provider Enumeration Date	:	10/15/2007
Last Update Date	:	07/09/2010

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Directions to “EAST COAST PODIATRY INC ” Practice Location

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